IntraPet Ultrasound Patient Information Form

To schedule, please

TEXT: 410-849-6867 or

🐾

DATE OF ULTRASOUND APPOINTMENT: Date is CONFIRMED with IntraPet and Hospital. A CONFIRMED appointment indicates Hospital has agreed pay Ultrasound exam fee or cancellation fees if applicable.

REQUESTED DATES for ultrasound (if not already confirmed with IntraPet, format: month/day).

Notes regarding scheduling may be added here

DVM Name

Hospital Name (No acronyms or #’s)*

Pet Name*

Owner Last Name *

Date of Birth*

Date

Weight (specify lbs or kg)*

Species/Breed*

Sex*

Ultrasound Exam-select all that apply. (Abdominal includes urinary & repro)*

If Specialty or Procedure specify type:

(Urinary, Thyroid, Chest, Pregnancy, FNA)

Previous IntraPet Ultrasound?*

Date of Previous IntraPet Ultrasound

PLEASE SPECIFY ECHO OR ABD

If concern for second cavity pathology is seen during a scan, (ex: splenic mass, pleural effusion, enlarged abd vessels), a limited second cavity scan is approved at $35*

Fee applies regardless of whether pathology is seen.

Presenting Complaint/History/PE*

PLEASE INCLUDE GRADE OF MURMUR IF APPLIES

Tentative diagnosis/ Questions to be answered with ultrasound*

Brief abnormalities for Lab Results/Radiograph Findings (please upload full results or email intrapetstaff@gmail)

*PLEASE DO NOT INCLUDE ENTIRE MEDICAL CHARTS/VISIT NOTES ETC. LABS/RADS/TEST RESULTS ONLY

Medications with dosage and duration

Sedation is NOT a requirement, it is recommended with some patients to achieve a diagnostic ultrasound, but it is ultimately the decision of DVM and the owner. *Certain sedatives interfere with echocardiograms, please contact us with any questions scan or injection.

Sedation— any instructions can be listed in box below*

YES, IV sedation is approved IF deemed necessary during the ultrasound. We use sedation if we cannot accomplish a diagnostic scan without it.YES, Intramuscular sedation — The hospital agrees to pay a fee if sedation is not administered at IntraPet arrival, I agree to enter contact info below.NO, sedation is declined. I accept the conditions stated below*

PRE-ARRIVAL: Please enter TEXT number (or email), this is not for voice calling. The sonographer will text or email 5-60 minutes prior to arrival and will notify staff when they enter the hospital.

Want us to provide an estimated 4 hour window the morning of your exam? Great! Feel free to text/call/email us at 410-849-6867 or intrapetstaff@gmail.com by 8 am on appt day!

Please note this is not a guaranteed window unless pre-arranged and fee collected. All patients must be dropped off by 745 am.

Thank you!!

*CONDITIONS FOR SEDATION CHOICE "NO":

If sedation choice is "NO", this indicates DVM/owner have declined sedation. IntraPet will not ask for sedation at the time of the scan if "NO" is selected, even if patient condition does not allow for a full diagnostic scan. A fee may apply

Sedation: please type dosages (or “in medical chart”) and any information regarding sedation.

SEDATION DOSES MUST BE AVAILABLE AT THE TIME OF THE SCAN HERE OR IN MEDICAL RECORD

Confidential questions/concerns, information for specialist/sonographer. WILL NOT APPEAR ON FINAL REPORT

Lab work / Rads

function SvgDhtupload2(props) { return /* @__PURE__ */ react.createElement("svg", dhtupload_svg_extends({ width: 54, height: 47, xmlns: "http://www.w3.org/2000/svg" }, props), dhtupload_svg_path || (dhtupload_svg_path = /* @__PURE__ */ react.createElement("path", { d: "M40.213 10.172c1.897.21 3.68.738 5.35 1.58a15.748 15.748 0 0 1 4.374 3.242 15.065 15.065 0 0 1 2.951 4.533c.72 1.704 1.08 3.522 1.08 5.455 0 1.827-.28 3.654-.843 5.48-.562 1.828-1.379 3.47-2.45 4.929A13.39 13.39 0 0 1 46.669 39c-1.599.948-3.452 1.458-5.56 1.528H37.26a1.62 1.62 0 0 1-1.185-.5 1.62 1.62 0 0 1-.501-1.186c0-.457.167-.852.5-1.186.334-.334.73-.5 1.186-.5h3.848c1.44 0 2.75-.37 3.926-1.108a10.851 10.851 0 0 0 3.03-2.846 13.53 13.53 0 0 0 1.95-3.9 14.23 14.23 0 0 0 .686-4.321c0-1.582-.316-3.066-.949-4.454a11.623 11.623 0 0 0-2.582-3.636 12.857 12.857 0 0 0-3.742-2.478 11.054 11.054 0 0 0-4.48-.922l-1.212-.053-.37-1.159c-.878-2.81-2.292-4.998-4.242-6.562-1.95-1.563-4.594-2.345-7.932-2.345-2.108 0-4.005.36-5.692 1.08-1.686.72-3.136 1.722-4.348 3.005-1.212 1.282-2.143 2.81-2.793 4.585-.65 1.774-.975 3.68-.975 5.718h.053l.105 1.581-1.528.264c-1.863.316-3.444 1.317-4.744 3.004-1.3 1.686-1.95 3.584-1.95 5.692 0 2.39.8 4.462 2.398 6.219 1.599 1.757 3.488 2.635 5.666 2.635h4.849c.492 0 .896.167 1.212.5.316.335.474.73.474 1.187 0 .456-.158.852-.474 1.185-.316.334-.72.501-1.212.501h-4.849a10.08 10.08 0 0 1-4.374-.975 11.673 11.673 0 0 1-3.61-2.661 13.173 13.173 0 0 1-2.478-3.9A12.073 12.073 0 0 1 0 28.301c0-2.706.755-5.148 2.266-7.326 1.511-2.178 3.444-3.636 5.798-4.374.14-2.354.658-4.542 1.554-6.562.896-2.02 2.091-3.777 3.584-5.27 1.494-1.494 3.25-2.662 5.27-3.505C20.493.422 22.733 0 25.193 0c1.898 0 3.637.237 5.218.711 1.581.475 3.004 1.151 4.269 2.03a13.518 13.518 0 0 1 3.268 3.215 18.628 18.628 0 0 1 2.266 4.216Zm-11.964 13.44 6.22 6.85c.245.247.368.537.368.87 0 .334-.123.642-.369.923l-.421.263c-.211.246-.484.343-.817.29a1.544 1.544 0 0 1-.87-.448l-3.69-4.11v16.97c0 .492-.166.896-.5 1.212-.334.316-.729.474-1.186.474-.492 0-.896-.158-1.212-.474-.316-.316-.474-.72-.474-1.212V28.25l-3.584 4.005a1.544 1.544 0 0 1-.87.448.959.959 0 0 1-.87-.29l-.42-.264c-.247-.28-.37-.588-.37-.922 0-.334.123-.624.37-.87l6.113-6.746v-.052l.421-.422a.804.804 0 0 1 .396-.29c.158-.053.307-.079.448-.079.175 0 .333.026.474.079.14.053.281.15.422.29l.421.422v.052Z", fill: "none" }))); }

Yes, employee pet No, not employee pet* Employee name matches patient name.

STAT is approved if emergency and patient is in critical condition. (Please note that preliminary findings may change this answer and will be discussed with DVM)*

YES, stat is approved if DVM on site deems necessary.NO, stat is not approved.PLEASE SUBMIT STAT REGARDLESS OF FINDINGS

Please enter your Email to receive a PDF copy of this form for your records. Your form will be editable from the link you receive at this email.*

example@example.com

Secondary email if above email is not clinic email.

example@example.com

I have contacted IntraPet by text or separate email to schedule this exam:*

YES, I have contacted IntraPet.NO, I have not contacted IntraPet and will do so after this form submission.

TEXT/CALL 410-849-6867 or EMAIL intrapetstaff@gmail

THANK YOU!

IntraPet Patient Information